Hindawi Publishing Corporation
Case Reports in Ophthalmological Medicine
Volume 2014, Article ID 135252, 3 pages
http://dx.doi.org/10.1155/2014/135252
Case Report
Huge Cavernous Hemangiomas Enveloping the Optic Nerve
Successfully Removed by a Vertical Lid Split Orbitotomy
Jung-Hoon Yum,1 Yoon-Duck Kim,2 Jung Hye Lee,3 and Kyung In Woo2
1
Department of Ophthalmology, Inje University Ilsan Paik Hospital, 170 Juhwa-ro, Ilsanseo-gu, Goyang 411-706, Republic of Korea
Department of Ophthalmology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong,
Gangnam-gu, Seoul 135-710, Republic of Korea
3
Department of Ophthalmology, Kim’s Eye Hospital, Myung-Gok Eye Research Institute, Konyang University College of Medicine,
156 Yeongdeungpo-dong, Yeongdeungpo-gu, Seoul 150-034, Republic of Korea
2
Correspondence should be addressed to Yoon-Duck Kim; [email protected]
Received 23 October 2013; Accepted 3 February 2014; Published 29 April 2014
Academic Editors: K. G. Boboridis and D. Goldblum
Copyright © 2014 Jung-Hoon Yum et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
A 63-year-old woman presented with a 15-year history of gradually increasing proptosis of right eye. Ocular examination revealed
proptosis of 9 mm with decreased visual acuity in her right eye. CT scan showed a well-circumscribed and enhancing orbital
mass filling almost the entire right orbit. The tumor occupied the superolateral, superomedial, and inferomedial intraconal space,
enveloping the optic nerve. Complete excision of two large intraconal tumors was performed successfully via a vertical lid split
orbitotomy. Histopathologic examination confirmed the diagnosis of cavernous hemangioma. There were no intraoperative or
postoperative complications. The patient achieved a satisfactory cosmetic outcome 1 year after surgery.
1. Introduction
A lateral orbitotomy can be used as a primary approach
for surgical removal of cavernous hemangioma located
intraconally [1]. It is challenging to decide the appropriate
surgical approach to remove large tumor when it is located
in the medial intraconal space [2]. Approaches which have
been described to excise large intraconal tumors include
combined medial and lateral orbitotomy or circumferential
pan-orbitotomy [3]. The current case illustrates successful
excision of huge intraconal cavernous hemangiomas enveloping the optic nerve via a vertical lid split orbitotomy.
2. Case Report
A 63-year-old female presented to our clinic with a painless
and prominent right eye of 15 years duration (Figure 1(a)).
When she first presented to us 14 years ago, she had no significant past medical history of note. Her visual acuity was 20/20
in both eyes. Hertel exophthalmometry measurement was
13.5 mm in the right eye and 10 mm in the left eye. Computed
tomography (CT) scan showed well-demarcated, enhancing
intraconal vascular tumor surrounding the optic nerve in
the right orbit. After that time, she was lost to follow up.
Two years ago, she revisited our clinic with progressive visual
disturbance in her right eye. On ophthalmic examination,
best corrected visual acuity was 20/200 OD and 20/20 OS.
Hertel ophthalmometry revealed 9 mm proptosis of the right
eye. There was a relative afferent pupillary defect and a color
vision defect in the right eye. On fundus examination, she
had mild elevation of the right optic disc. Goldmann visual
field demonstrated a central and temporal scotoma of the
right eye. Visual evoked potential (VEP) showed delay in P100
and decreased amplitude in the right eye. CT scan showed
that the tumor occupied the superolateral, superomedial,
and inferomedial intraconal spaces, enveloping the optic
nerve and displaced the globe anteriorly and inferolaterally.
The size of the tumor was larger as compared to 14 years
ago (Figure 1(b)). MRI revealed the tumor was hypointense
on T1-weighted sequence and hyperintense on T2-weighted
sequence and demonstrated progressive filling on gadolinium enhanced sequences (Figure 1(c)). A vertical lid split
2
Case Reports in Ophthalmological Medicine
(a)
(b)
(c)
Figure 1: (a) Preoperative clinical photography shows the significant proptosis and inferolateral displacement of right eye. (b) CT scan of
initial presentation shows well-demarcated enhancing intraconal vascular tumor in the right orbit. (c) 14 years later, MRI showing hypointense
masses on T1-weighted sequence and hyperintense on T2-weighted sequence and demonstrating dense contrast enhancement. The optic nerve
is surrounded and compressed by tumor (black arrow).
(a)
(b)
(c)
(d)
Figure 2: (a) Full thickness vertical lid marginal incision is made at the junction of the medial and central thirds of the upper lid. (b) After all
adhesions were released carefully, the two tumors were removed successfully. (c) The lid incision was repaired by the same method used for
repair of a full thickness lid margin laceration. (d) Histopathologic examination reveals cavernous hemangioma consisting of dilated spaces
filled with blood and septated by fibrous tissues (hematoxylin-eosin, X50).
orbitotomy was performed to remove the tumor. The larger
tumor was firmly attached to the smaller tumor with fibrous
band and the optic nerve was located between two tumors.
Careful dissection was performed, so as not to damage the
optic nerve. After all fibrous adhesions between two tumors
were released, the larger tumor was removed successfully
and then smaller tumor was removed safely. The lid incision
was repaired with a similar method used for repair of a
full thickness lid margin laceration. The masses measured
5 × 3 × 1 cm and 3 × 1 × 1 cm, respectively. Histopathologic examination confirmed the diagnosis of cavernous
hemangiomas (Figure 2). There was no intraoperative complication, and the patient’s recovery was uneventfully. At
postoperative 6 months, best corrective visual acuity of the
right eye was improved to 20/50. There was satisfactory
cosmesis with no eyelid dysfunction. CT scan of the orbit
showed no residual tumor in the orbit (Figure 3).
3. Discussion
Several surgical approaches for intraconal orbital tumor have
been described in relation to the location and size of the lesion
Case Reports in Ophthalmological Medicine
3
References
(a)
(b)
Figure 3: (a) Postoperatively, photographs showing that proptosis
is improved with good cosmesis. (b) Postoperative CT scan demonstrating the complete removal of the tumors.
[1–3]. Lateral orbitotomy has been the preferred method to
excise the cavernous hemangiomas as they are usually located
intraconally and laterally. The removal of large cavernous
hemangiomas in the medial intraconal space is challenging
for complete excision without complications because visualization of tumor is limited and there are high density of
critical normal structures often associated with substantial
attachment to the tumor [2–4]. An anterior orbitotomy via an
upper eyelid crease incision requires transection of the levator
aponeurosis and Müller’s muscle to reach to the intraconal
space. In addition, disinsertion of medial rectus muscle is
also needed in the medial approach. Transcranial approach
or circumferential pan-orbitotomy is invasive procedure and
spends much operative time [3].
Byron Smith reported the vertical lid split orbitotomy for
removal of superonasal anterior orbital tumors [5]. Kersten
and Kulwin described the detailed procedure of the vertical
lid split approach [6]. This approach provides excellent
exposure of the superomedial orbit and is a very useful
approach to access lesions that lie in medial to the optic nerve
[7].
In our case, the larger tumor was located at the superomedial part of the orbit and attached to another tumor laterally,
enveloping the optic nerve. With its close proximity to the
optic nerve, dissection of the tumors was challenging. We
excised the tumors completely via vertical lid split orbitotomy
and saved operation time. The patient recovered fast and had
an uneventful postoperative period.
In conclusion, the huge intraconal cavernous hemangiomas could be safely removed via vertical lid split orbitotomy. Postoperatively, it maintains the normal eyelid function and yields good cosmetic outcome. It is an excellent alternative approach to extract large intraconal, well
encapsulated tumor which is superomedially located in the
orbit.
Conflict of Interests
The authors declare that they have no conflict of interests
regarding this paper.
[1] J. A. Shields, C. L. Shields, and R. C. Eagle, “Cavernous hemangioma of the orbit,” Archives of Ophthalmology, vol. 105, no. 6, p.
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[3] J. Rootman, B. Stewart, and R. A. Goldberg, Eds., Orital
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[4] R. W. Pelton and B. C. K. Patel, “Superomedial lid crease
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[5] B. Smith, “The anterior surgical approach to orbital tumors.,”
Transactions of the American Academy of Ophthalmology and
Otolaryngology, vol. 70, no. 4, pp. 607–611, 1966.
[6] R. C. Kersten and D. R. Kulwin, “Vertical lid split orbitotomy
revisited,” Ophthalmic Plastic and Reconstructive Surgery, vol. 15,
no. 6, pp. 425–428, 1999.
[7] V. Prabhakaran and D. Selva, “Vertical lid split approach for
optic nerve sheath decompression,” Indian Journal of Ophthalmology, vol. 57, no. 4, pp. 305–306, 2009.
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